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Shimoni Z, Salama H, Finn T, Froom P. Is It Safe to Treat Stable Patients with Bacteremic Urinary Tract Infections with High-Resistant-Rate Antibiotics? Diagnostics (Basel) 2024; 14:1620. [PMID: 39125496 PMCID: PMC11311597 DOI: 10.3390/diagnostics14151620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/18/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES In most areas of the world, urine bacteria have high resistance rates to third-generation cephalosporins, and it is unclear if it is safe to treat stable patients with bacteremic urinary tract infections (UTI) with those antibiotics. There are recommendations that empiric therapy for a suspected UTI should include only antibiotics with resistance rates less than 10%. MATERIALS AND METHODS In this historical observational single center study, we selected 180 stable internal medicine patients hospitalized between January 2019 and December 2021, with identical bacteria isolated from blood and urine cultures. Charts were reviewed to determine if deaths and readmissions up to 30 days after discharge were due to bacterial resistance to initial antibiotic therapy (BRIAT). RESULTS The patient's median age was 82 years (1st-3rd quartiles, 73-87 years). A total of 54.4% were female. There were 125 patients treated with ceftriaxone. A total of 38 (30.3%) had BRIAT. Four patients died, but none were because of a delay in appropriate treatment. The median days of hospitalization for all patients was 7 days, and 9 days versus 6 days in those with and without BRIAT. There were no re-hospitalizations for a UTI in patients with BRIAT. CONCLUSIONS We conclude that, despite high resistance rates, empiric ceftriaxone in stable hospitalized patients with a bacteremic UTI is safe. There was no urosepsis-related mortality during the hospitalization or on follow-up. The treatment of all patients with wider-spectrum antibiotics might have decreased the median hospital stay by only one day. The potential effect would be even lower if all patients with a suspected systemic UTI were treated with wide-spectrum antibiotics, because some patients do not have an infection of the urinary tract. A reassessment of the recommendation that empiric therapy for a suspected systemic urinary tract infection should include only wider-spectrum antibiotics is warranted.
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Affiliation(s)
- Zvi Shimoni
- The Adelson School of Medicine, Ariel University, Ariel 4070001, Israel; (Z.S.); (T.F.)
- Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel
| | - Hanna Salama
- Internal Medicine Department A, Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel;
| | - Talya Finn
- The Adelson School of Medicine, Ariel University, Ariel 4070001, Israel; (Z.S.); (T.F.)
- Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel
| | - Paul Froom
- Clinical Utility Department, Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel
- School of Public Health, University of Tel Aviv, Tel Aviv 6997801, Israel
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Froom P, Shimoni Z. Laboratory Tests, Bacterial Resistance, and Treatment Options in Adult Patients Hospitalized with a Suspected Urinary Tract Infection. Diagnostics (Basel) 2024; 14:1078. [PMID: 38893605 PMCID: PMC11172264 DOI: 10.3390/diagnostics14111078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Patients treated for systemic urinary tract infections commonly have nonspecific presentations, and the specificity of the results of the urinalysis and urine cultures is low. In the following narrative review, we will describe the widespread misuse of urine testing, and consider how to limit testing, the disutility of urine cultures, and the use of antibiotics in hospitalized adult patients. Automated dipstick testing is more precise and sensitive than the microscopic urinalysis which will result in false negative test results if ordered to confirm a positive dipstick test result. There is evidence that canceling urine cultures if the dipstick is negative (negative leukocyte esterase, and nitrite) is safe and helps prevent the overuse of urine cultures. Because of the side effects of introducing a urine catheter, for patients who cannot provide a urine sample, empiric antibiotic treatment should be considered as an alternative to culturing the urine if a trial of withholding antibiotic therapy is not an option. Treatment options that will decrease both narrower and wider spectrum antibiotic use include a period of watching and waiting before antibiotic therapy and empiric treatment with antibiotics that have resistance rates > 10%. Further studies are warranted to show the option that maximizes patient comfort and safety.
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Affiliation(s)
- Paul Froom
- Clinical Utility Department, Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel
- School of Public Health, University of Tel Aviv, Tel Aviv 6997801, Israel
| | - Zvi Shimoni
- The Adelson School of Medicine, Ariel University, Ariel 4070000, Israel;
- Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel
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Shimoni Z, Salah M, Kasem A, Hermush V, Froom P. Bacterial Resistance to Cephalosporin Treatment in Elderly Stable Patients Hospitalized With a Urinary Tract Infection. Am J Med Sci 2020; 360:243-247. [PMID: 32482350 DOI: 10.1016/j.amjms.2020.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/13/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND It is unclear if parenteral cephalosporin treatment is appropriate in stable elderly patients hospitalized with a urinary tract infection (UTI) in settings with a high prevalence of bacterial resistant organisms. METHODS We selected 934 consecutive stable patients aged ≥65 years with a UTI, 94.4% (n = 882) treated with a parenteral cephalosporin. Patients were divided into those with and without bacterial resistance to initial antibiotic therapy (BRIAT). Outcome measures were response to antibiotic therapy at 72 hours, prolonged hospitalization (>5 days) and mortality. RESULTS There were 316 patients (33.8%) with BRIAT. At 72 hours, 33.9% (107/316) did not respond to initial treatment. The odds of a prolonged hospitalization was 2.1 (95% confidence interval-1.6-2.9), but no patient with BRIAT died from urosepsis (0%, 95% confidence interval-0-1.2%). CONCLUSIONS In elderly stable patients hospitalized with a UTI, treatment with a parenteral cephalosporin might be appropriate despite a high prevalence of resistant organisms.
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Affiliation(s)
- Zvi Shimoni
- Department of Internal Medicine B, Sanz Medical Center, Netanya, Israel; Ruth and Bruce Rappaport School of Medicine, Haifa, Israel
| | - Mohamed Salah
- Department of Internal Medicine B, Sanz Medical Center, Netanya, Israel
| | - Amrani Kasem
- Department of Internal Medicine B, Sanz Medical Center, Netanya, Israel
| | - Vered Hermush
- Department of Geriatrics, Sanz Medical Center, Netanya, Israel
| | - Paul Froom
- Department of Clinical Utility, Sanz Medical Center, Netanya, Israel; School of Public Health, University of Tel Aviv, Israel.
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Godbole GP, Cerruto N, Chavada R. Principles of assessment and management of urinary tract infections in older adults. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Gauri P. Godbole
- Pharmacy Department Gosford Hospital, NSW Health Gosford Australia
| | - Nicole Cerruto
- Pharmacy Department Gosford Hospital, NSW Health Gosford Australia
| | - Ruchir Chavada
- Department of Microbiology and Infectious Diseases NSW Health Pathology Central Coast Newcastle Australia
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Shimoni Z, Cohen R, Froom P. Prevalence, impact, and management strategies for asymptomatic bacteriuria in the acute care elderly patient: a review of the current literature. Expert Rev Anti Infect Ther 2020; 18:453-460. [PMID: 32212977 DOI: 10.1080/14787210.2020.1746642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: It is unclear how to prevent the negative impact of inappropriate urine cultures in older acute care patients who have a high rate of asymptomatic bacteriuria.Areas covered: A nonsystematic literature review of the definition, impact, and management of elderly acute care patients with asymptomatic bacteriuria (ASB).Expert opinion: In the elderly, patients with ASB include those with extra-urinary tract diseases (e.g. pneumonia) and those with symptoms/signs that resolve without antibiotic therapy, but the diagnosis of ASB is unclear in febrile patients responding to antibiotics. We consider four management strategies that could decrease the negative impact of culturing the urine including unnecessary antibiotic therapy in those with ASB: (1) Prevent urine testing in patients with extra-urinary tract reasons for their acute care (2) Cancel urine cultures if the urine dipstick is negative. (3) Avoid catheterization in stable patients who cannot provide a urine specimen on demand and (4) Withhold antibiotics in stable non-febrile elderly patients who do not have new local urinary tract symptoms or decompensation on follow-up, and pursue further investigations for another etiology/diagnosis.
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Affiliation(s)
- Zvi Shimoni
- Department of Internal Medicine B, Sanz Medical Center, Netanya, Israel.,Ruth and Bruce Rappaport School of Medicine, Haifa, Israel
| | - Regev Cohen
- Department of Infectious Disease, Sanz Medical Center, Netanya, Israel
| | - Paul Froom
- Department of Clinical Utility, Sanz Medical Center, Netanya, Israel.,School of Public Health, University of Tel Aviv, Tel Aviv, Israel
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Dokter J, Tennyson LE, Nguyen L, Han E, Sirls LT. The clinical rate of antibiotic change following empiric treatment for suspected urinary tract infections. Int Urol Nephrol 2019; 52:431-436. [PMID: 31691136 DOI: 10.1007/s11255-019-02327-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/28/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE To determine the rate of antibiotic change in an outpatient setting following empiric treatment of culture proven UTI and to identify risk factors associated with change. METHODS Patients with suspected UTI and urine culture were reviewed (January 2016-June 2016). Those with a positive culture were categorized by whether or not they were treated empirically. Empiric treatment was evaluated for associations with clinical-demographic data, symptoms and urinalysis (UA). Antibiotic change was evaluated with clinical-demographic data, urine culture, and resistance patterns. RESULTS 916 urine cultures (636 patients) were included. 391 (43%) cultures were positive, and 164 (42%) were treated empirically. Clinical-demographic data did not differ between groups. Those treated empirically had more documented UTI symptoms (93 vs 58%, P < 0.001), and UA abnormalities including positive nitrites (51 vs 29%, P < 0.001), 3 + leukocyte esterase (27 vs 19%, P = 0.002) and 3 + blood (13 vs 4%, P = 0.005). Of those treated empirically, 42/164 (26%) required an antibiotic change, and this was associated with immunosuppression (12 vs 2%, P = 0.027) resistance to > 3 antibiotics (33 vs 20%, P = 0.039) and also resistance to fluoroquinolone (50 vs 30%, P = 0.016), monobactam (19 vs 7% P = 0.042) and TMP-SMX (52 vs 19%, P < 0.001). CONCLUSIONS Almost one-quarter of patients treated empirically required antibiotic change. This was driven largely by bacterial resistance. New technologies allowing rapid bacterial identification and sensitivity may improve patient care.
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Affiliation(s)
- Jonathan Dokter
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Lauren E Tennyson
- Department of Urology, Female Pelvic Medicine and Reconstructive Surgery, Beaumont Health, 3535 W. 13 Mile Road, Suite 438, Royal Oak, MI, 48073, USA.
| | - Laura Nguyen
- Department of Urology, McMaster University, Hamilton, ON, Canada
| | - Esther Han
- Department of Urology, Female Pelvic Medicine and Reconstructive Surgery, Beaumont Health, 3535 W. 13 Mile Road, Suite 438, Royal Oak, MI, 48073, USA
| | - Larry T Sirls
- Department of Urology, Female Pelvic Medicine and Reconstructive Surgery, Beaumont Health, 3535 W. 13 Mile Road, Suite 438, Royal Oak, MI, 48073, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Coudert M, Pépin M, de Thezy A, Fercot E, Laycuras M, Coudert AL, Duran C, Bouchand F, Davido B, Le Crane M, Denis B, Muller F, Gourdon M, Peng CL, Mahamdia R, Mekerta Z, Seridi Z, Gaillard JL, Leichowski L, Moulias S, Rottman M, Sivadon-Tardy V, Teillet L, Dinh A. Présentation clinique et performance de la bandelette urinaire pour le diagnostic d’infection urinaire en population gériatrique. Rev Med Interne 2019; 40:714-721. [DOI: 10.1016/j.revmed.2019.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 11/30/2022]
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Shimoni Z, Evgeniy S, Froom P. Urine catheterization of elderly hospitalized patients unable to provide a urine sample for culture. J Infect 2019; 79:389-399. [DOI: 10.1016/j.jinf.2019.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 07/30/2019] [Accepted: 08/03/2019] [Indexed: 11/26/2022]
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Froom P, Shimoni Z. The uncertainties of the diagnosis and treatment of a suspected urinary tract infection in elderly hospitalized patients. Expert Rev Anti Infect Ther 2018; 16:763-770. [DOI: 10.1080/14787210.2018.1523006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Paul Froom
- Clinical Utility Department Sanz Medical Center, Laniado Hospital, Netanya, Israel and School of Public Health, University of Tel Aviv, Ramat Aviv, Israel
| | - Zvi Shimoni
- Department of Internal Medicine B, Laniado Hospital, Netanya, Israel;and Ruth and Bruce Rappaport School of Medicine, Haifa, Israel
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No need for a urine culture in elderly hospitalized patients with a negative dipstick test result. Eur J Clin Microbiol Infect Dis 2018; 37:1459-1464. [DOI: 10.1007/s10096-018-3271-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/02/2018] [Indexed: 10/16/2022]
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Howard-Anderson J, Schwab K, Quinn R, Graber CJ. Choosing Wisely Overnight? Residents' Approach to Fever. Open Forum Infect Dis 2017. [PMID: 28638842 PMCID: PMC5473033 DOI: 10.1093/ofid/ofx080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We surveyed internal medicine residents regarding how they approach febrile patients in cross-cover settings. Residents frequently use the term “full fever work-up,” and rely on this for sign-out. Despite this, residents felt fever work-ups were not evidenced-based, and definitions of when and how to respond to a fever varied.
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Affiliation(s)
- Jessica Howard-Anderson
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles
| | - Kristin Schwab
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles
| | - Roswell Quinn
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles.,Hospitalist Division of the Department of Medicine and
| | - Christopher J Graber
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles.,Infectious Diseases Section, VA Greater Los Angeles Healthcare System, California
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